Stroke is one of the top 10 causes of death in children in the U.S.  Signs of stroke are often missed in children and teens because of a lack of awareness, we think of geriatric, not pediatric stroke.

AIS (arterial ischemic stroke) accounts for about half of all strokes in children, in contrast to adults in whom 80–85% of all strokes are ischemic.  Children also have a more diverse and larger number of risk factors for stroke that differ significantly from adults which are predominated by hypertension, diabetes, and atherosclerosis. (Tsze & Valente, 2011)

10–25% of children with a stroke will die, up to 25% of children will have a recurrence, and up to 66% will have persistent neurological deficits or develop subsequent seizure disorders, learning, or developmental problems.  Given the onset of impairment during childhood and the effect on quality of life for the child and family, the economic and emotional costs to society are amplified.

There are some generalizations that can be made as to how strokes present in children. AIS most often presents as a focal neurologic deficit. Hemiplegia is the most common focal manifestation, occurring in up to 94% of cases. Hemorrhagic strokes most commonly present as headaches or altered level of consciousness and are more likely to cause vomiting than in AIS. Seizures are common in both ischemic and hemorrhagic strokes. They occur in up to 50% of children with strokes, are not restricted to any age group, and are not limited to any specific seizure type.

Patient presentation varies with age.   Perinatal strokes are more likely to initially present with focal seizures or lethargy in the first few days after birth.  Although focal neurological deficits from these events may not develop until weeks or months later, infants within the first year of life can still present acutely with lethargy, apnea spells, or hypotonia. Toddlers can also present with protean symptoms such as deterioration of their general condition, increased crying and sleepiness, irritability, feeding difficulty, vomiting, and sepsis-like symptoms with cold extremities. Older children demonstrate more specific neurological defects similar to adults.

The average time from symptom onset to presentation to the hospital for children with AIS has been reported in older literature to be 24 h (Jordan & Hillis, Challenges in the diagnosis and treatment of pediatric stroke, 2011).  Symptom onset is often rapid and dramatic in children with hemorrhagic stroke, occurring over minutes to hours.

Diffusion-weighted MRI of the brain is the most sensitive method to diagnose acute AIS; however, in children aged <8 years old, sedation or anesthesia may be required to undergo such imaging, as individuals must hold still for an extended period of time. In general, head CT generally does not require patient sedation, but the sensitivity of this method to detect acute AIS is low.

Arterial ischemic stroke therapy includes both antiplatelet (typically aspirin) and anticoagulant (unfractionated heparin, low molecular weight heparin, and warfarin) medications. Of note, the only treatments that limit brain injury after stroke are therapies that promote reperfusion, for example, tPA and mechanical clot retrieval, or reduce metabolic demands (avoiding hyperpyrexia or hyperglycemia); all other interventions are designed for secondary stroke prevention. Thrombolytic therapy is often used to treat arterial ischemic stroke in children, despite lack of FDA approval in this age group. The International Pediatric Stroke Study investigators have assessed the extent and nature of recombinant tissue plasminogen activator use in children in their registry and have compared their findings with previously published case reports. (Jordan, Stroke: Thrombolysis in childhood arterial ischemic stroke, 2009)

Children with sickle cell disease (SCD) are the exception amongst older children with AIS; aspirin and anticoagulation aren’t typically recommended. Instead, transfusions are recommended to lower the percentage of sickle hemoglobin to <30%.  Evidence for acute transfusion in the setting of first-ever AIS is not as strong, although acute transfusions are commonly performed in clinical practice.

For hemorrhagic strokes the role of surgical evacuation of hemorrhage in children and young adults, <45 years of age with ICH is yet another controversial area of stroke therapy.  Despite strong evidence for endovascular therapy in adults with acute arterial ischemic stroke, limited data exist in children.  In a national sample of children with a diagnosis of arterial ischemic stroke, endovascular therapy was infrequently utilized (Wilson, Eriksson, & Williams, 2017)

I find no references to pediatric stroke in the 2020 AHA ACLS or PALS provider manuals.  Immediately calling an ambulance is the key factor in reducing time to hospital presentation for adult stroke. Little is known about prehospital care in childhood arterial ischemic stroke (AIS). (Stojanovski, et al., 2017).  Sensitivity of paramedic stroke identification in adults varies from 44-66% but there are no published data in children (Stojanovski, et al., 2016)

The PedNIHSS was developed by pediatric and adult stroke experts by modifying each item of the adult NIH Stroke Scale (NIHSS) for children, retaining all exam items and scoring ranges of the NIHSS.  Examiners in our study were child neurologists and child neurology trainees. This limits the generalizability of our findings on IRR with respect to the examining health care provider.

Pediatric National Institutes of Health Stroke Scale (PedNIHSS) https://www.ebmedicine.net/media_library/files/Pediatric-Stroke-CD.pdf

I’m unable to find any prehospital assessment for pediatric stroke.  Internet search for prehospital pediatric stroke assessment led to FAST or Cincinnati Prehospital Stroke Scale.  Until I find one for the infant or small child,  I’m going to document moving all arms and legs.

Bibliography

https://www.stroke.org/en/about-stroke/stroke-in-children/pediatric-stroke-infographic. (n.d.). AHA.

Jordan, L. C. (2009). Stroke: Thrombolysis in childhood arterial ischemic stroke. Nature Reviews Neurology, 5(9), 473-474. Retrieved 9 29, 2023, from https://ncbi.nlm.nih.gov/pubmed/19724299

Jordan, L. C., & Hillis, A. E. (2011). Challenges in the diagnosis and treatment of pediatric stroke. Nature Reviews Neurology, 7(4), 199-208. Retrieved 9 29, 2023, from https://ncbi.nlm.nih.gov/pmc/articles/pmc3383861

Stojanovski, B., Monagle, P., Mosley, I., Churilov, L., Newall, F., Hocking, G., & Mackay, M. T. (2017). Prehospital Emergency Care in Childhood Arterial Ischemic Stroke. Stroke, 48(4), 1095-1097. Retrieved 9 29, 2023, from https://ahajournals.org/doi/full/10.1161/strokeaha.116.014768

Stojanovski, B., Monagle, P., Newall, F., Churilov, L., Mosley, I., Hocking, G., & Mackay, M. T. (2016). Abstract WMP101: Paramedic Management of Childhood Arterial Ischemic Stroke. Stroke, 47. Retrieved 9 29, 2023, from https://ahajournals.org/doi/abs/10.1161/str.47.suppl_1.wmp101

Tsze, D. S., & Valente, J. H. (2011). Pediatric Stroke: A Review. Emergency Medicine International, 2011, 734506-734506. Retrieved 9 29, 2023, from https://ncbi.nlm.nih.gov/pmc/articles/pmc3255104

Wilson, J. L., Eriksson, C. O., & Williams, C. N. (2017). Endovascular Therapy in Pediatric Stroke: Utilization, Patient Characteristics, and Outcomes. Pediatric Neurology, 69, 87-92. Retrieved 9 29, 2023, from https://sciencedirect.com/science/article/pii/s0887899416310669